Healthcare Provider Details

I. General information

NPI: 1508269572
Provider Name (Legal Business Name): ORTHONOW WESTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2014
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 SW 148TH AVE
SOUTHWEST RANCHES FL
33330-2129
US

IV. Provider business mailing address

4825 SW 148TH AVE
SOUTHWEST RANCHES FL
33330-2129
US

V. Phone/Fax

Practice location:
  • Phone: 954-802-6763
  • Fax:
Mailing address:
  • Phone: 954-802-6763
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberHCC10353
License Number StateFL

VIII. Authorized Official

Name: ASHLEY BOLANOS
Title or Position: ADMINISTRATOR
Credential:
Phone: 954-802-6763